Bilateral Indwelling Pleural Catheter Placement for Advanced Non-small Cell Lung Cancer with Recurrent Pleural Effusion

CHAPTER 1

My name is Dr. Yu Maw Htwe. I am the assistant professor of the Intervention pulmonary program at Hershey Penn State Health. Today we will be performing the bilateral indwelling pleural catheter placement. This is a 56-year-old gentleman with a non-small cell lung cancer advanced with bilateral pleural effusion which is recurrent. And we have done at least two or three thoras each side. Every time he has symptom improvement and also oxygen requirement has gone down. But the last time we had tap is like a week ago. So he has very rapid reaccumulation. So there are indications for the indwelling pleural catheter, one is the malignant pleural fusion. Second is recurrent, and then how fast it fills up, if it fills up every one, three month, then maybe indwelling pleural catheter is not a good choice. Another one that you want to look out for is how long he gonna live. He gonna die in a month? Then the expense that you expended for the indwelling pleural catheter is not worth it. So we are looking for the expectation around three month time point. So, and then the third one is, does he improve his quality of life? In his case, he did. So he has to come to the emergency room every other week or every week. And after we drain the thora and he was able to wake up and then go to the bathroom again, walk out his daily, can resume his daily activities again. So he has symptomatic relief benefit. So he check all the boxes. So we planning to do the bilateral indwelling pleural catheter placement.

CHAPTER 2

So this is a ultrasound image and then this is the diaphragm and that's the liver. This is the fluid part or whatever the black thing that you are seeing. So we need to see that diaphragm. And also it has to be kind of simple effusion to place a safe pocket area. So that's what David has been looking for. I think it's okay. Let's do it, okay? And now he already marked the place. He gonna mark it. So he is putting his finger so that he doesn't lose the space. So that is where we gonna go inside from the skin to the pleural space. And then he is making another marker. So that is where the catheter gonna come out. It is different than regular chest tube. And this is called tunnel pleural catheter. So from this side, this side's gonna go into the pleural space. And this side, the catheter gonna come out. Now we cleaning these areas. Like surgery - surgery, you have to wait for the three minutes. But here you don't necessarily need to because we are not using a cautery. So the fire risk is really low. This is a setup of the kind of rocket placement, right? So if you doing it by yourself, you have to be able to set it up like that. Now I want ultrasound. How are you doing, okay? So you cannot squirt it up like this so that if I need it, I can use it again. And right here. So I'm gonna check it again. It's a little, another cold gel, okay? Good. You can see it okay? Yeah, I'm doing okay. So I'm kind of trying to check my position, and then I think this is a good position. So I like it.

CHAPTER 3

So now I'm gonna numb up the skin. A little bit poke and burning. Okay? You're gonna have a little sting and a burn. Okay? So it's kind of a 35-degree angle and then make sure there is no blood vessel in it. And I give an ample amount, at least like three to four cc. Now I already numb this area, and then I'm gonna look for my pocket. So I kind of go to the same direction that I was look with the ultrasound, and then I numb along the track. A little bit poke. And burning. How are you doing? Okay, I'm numbing you really good. Thank you. Okay, now I got the fluid return back. You want to take a video here? Can you see it, the syringe? I'm gonna pull back and you see the fluid return. So which mean I'm in the space. So, then I can either give everything in and come out. The key thing is you don't want to give the lidocaine on the way out. That can cause the seeding, which is - cancer cells can spread along the wall. Now I'm gonna get another lido. This is to give the tract. So the tract's supposed to be on the same rib space. So I'm kind of looking into the rib space here. So what I'm gonna do is I'm gonna get from here - David, a little pinch and burn, okay? So do you see a little bit skin bulging? So I'm kind of numbing along the tract, which I'm going to make sure. And then from around that area, I'm gonna give another... Okay, I give it back. Now I'm gonna check again. Can I use this one? I like the one with a little bit of lido. Mm-hmm.

CHAPTER 4

A little bit pinch and burn, okay? Now you see I got the return, and then this hand is done very still and I unhook. And then this is my guidewire. Guidewire has to be very ready. And then I thread it. There is a mark, you see the two line and I go all the way to three line if possible. So now my guidewire goes in without any difficulty. So now, I want to see how far, so this guidewire is pretty long. Then I'm gonna thread it a little bit more because I want to keep the sterile space very good. Okay, so that is a good one. Then, the needle's gonna come out, and the guidewire's gonna stay in. We'll give it back to needle. Now we gonna check before we dilate or anything. So do you see kind of the white kind of line going in and out? That is a guidewire. That is a guidewire going there. You see it? Okay. So I am kind of satisfied with my placement. So I'm gonna make a skin nip here.

CHAPTER 5

You have it, your kind of blade on top of the wire and- a little bit poke, okay? And you go in. I know. Okay. You doing okay? And now I have to make another tract. You okay? So I'm gonna make another tract by doing another skin nip here. So I have to push my two finger here to prevent, and along this tract, my goal is I want to come out from this side. It hurts. I know. It hurts? Is it hurting? I know, I'm sorry. So it came out from here and here. This called tunnel. Okay, you are almost done. I'm sorry. You're doing very good. And then do you see the cuff? This cuff is, well some people say in the middle, but I kind of like it to be at the end. It should not come out of it because this is the only one that is kind of holding the tunnel in place. Okay? So I squeeze and I pull, squeeze and pull. Okay, now I am in it, so then I take it off this introduce and give it to them. Now that's why she has given this to me. So I'm gonna be kind of holding it here so that it stays.

CHAPTER 6

Now I'm gonna dilate. So I'm gonna use the two dilators. And dilator is very simple. You have to kind of go in and out. I'm sorry. And then when I get in, what I do is, I push it down and I push it in. So the dilator is gonna come out along with the- You see the fluids rushing?

CHAPTER 7

And now, okay, do we have a suction ready? I'm sorry. I'm sorry. It's almost done. So you feed it in all the way to the end. I know, I know, I know. And then you break it. I'm sorry. And now with one hand, while pressing the catheter down the other hand, pull the sheath back. I know. I'm sorry. We almost done. You're already, there is no sharp thing in your body, okay? One second. Okay, so now another key important thing is make sure it is not kinking. Okay, so there is no kink. Now I need to suction.

CHAPTER 8

Opened it. So right now this is a one way valve. That's why nothing come out. If I hook it up with this, it's gonna make a whole channel, and the fluid is gonna come out. So from here - so you connect with this. Oh, so what you do is you cut it here. Okay, that works. It should not be that challenging. So now I'm gonna connect this and then lock it. And then you see the fluid is coming out and then she gonna suction out. Can you slow down a little bit more? Maybe hundred? Uh-huh. Okay, now... Do you feel, do you feel it? Uh-huh. Okay, do you have any lido? Is it sharp or is it pressure? Pressure. Pressure? Okay. No, I think I'm okay. I know, I'm sorry. Okay, thank you. I don't think I needed it yet. And then I'm gonna just suture. Thank you. Oh yeah, because of this thing, you're not here. How are you doing? Good. Good? Let me know if you are short of breath. Okay, I think maybe you can stop for now. You got about five seven. Okay, so I'm gonna do another stitches here. You okay? I'm sorry. But we're almost done, okay? Okay. Hmm? Okay. What is that? It is from the suction. I gave you the sharp and there was another one. Okay, this one too. Okay. I'm sorry. Do we know how much did we take it out? 570. Can you take out a little bit more? You can start with a ten draw. Because I don't want him to be kind of- So this is kind of suturing. Okay. Yeah, yeah. So I'm just putting another suture in so that it maintains that chest tube in place. Let me see. I want to see how much fluid left. I think he got a lot more. Yeah, he should have a lot of more fluid left. Do you want me to drain more or you want to hold it off for now? You have a lot of fluid left. I think at least another thousand. Do you want her to drain a little bit more fluid off? Yes. Yeah, okay. I'm gonna start again here. It's a what? Okay. 800... I think he got like two liters. So this is a Dermabond. That place, it's kind of a glue. Maybe around a liter and we can stop, okay? Yeah, you can stop it. Okay. We are done with this side, okay? So this is a cap. No, I'm just waiting for the Dermabond to be dry fully. Okay. We are done actually. It's still your leg hurting? Yeah. It is? So, you have to make a kind of a coil and then cover this area. Only three. Three. Yeah. Four is a little bit too big. So now I'm gonna have you standing here and you have to remove all those. So before we do that, we're gonna use this one again right? Now, Julia, will you help me? Removing all those dressing. Be careful not to touch it because we're gonna use it again. Okay. Now let me see. Now can I get a tape? You got it right? I know. I'm sorry. We are done. Do you have another tegaderm, 4 x 4? I might, can I get like two? I'm sorry. You're doing great. I think I'm good. So now we can reposition.

CHAPTER 9

Oh okay, so this is me another marking. So this is a different probe because I don't want to kind of use that probe for now. So this is what- I know, I'm sorry. Okay, so, the white line is the diaphragm and below that is the spleen. Above is kind of pleural fluid. So I kind of like this angle here. So I'm gonna mark it. A little bit pressure. Okay, this is just to mark the site. This gonna be entry and this gonna be exit site. It's a little bit cold. Sure, I know. I'm sorry. And I'm just cleaning again. Okay. Do we have another lido, right? We do. This is just making a sterile field. So this is me again checking the position. So I like it. I'm checking the position. And do you see the diaphragm, spleen, and the fluid? A big pocket, which is like maybe 15 cm deep.

A little bit poke. Okay, a little stick and a burn here, okay? This is the numbing. And then so again I'm numbing the skin. So a little bit superficial. I give a lot at least like maybe 5 cc. And then now the same way, I'm gonna look for the pocket. So I go a little bit deeper. Numb. Apply negative pressure, go deeper. Numb. A little bit burning, okay? And then so you see the fluids come back. So I'm in the space. So what I'm gonna do, I'm gonna give all of the- inside the space not outside. And I come back. Now can I get another lido? I'm also looking for the same rib space. So I'm gonna numb the skin. Again. Pinch and burn. Okay, so I'm gonna go from this side a little bit. Okay, now can I get the needle, the big one? Yeah, that one. And can you hook it up with the syringe? Again, I'm checking the position. Okay, I'm ready.

Oh, okay. So I'm gonna go in the same direction that I went in. When I do the lido, okay, I got the fluid and I go a little bit deeper and then my hand is stable, tighten here and hook it. And then, thread the guidewire all the way to at least three, three lines that I'm seeing. But I'm gonna go a little bit deeper because I want to keep the sterile field. Okay. Guidewire in, needle gonna come out. One second. Now I'm gonna make my nip with the blade.

Thank you. So what I do is I kind of lean forward this guidewire and I have it on top of the guidewire. And a little bit of poke, sir. And I go all the way. And then a little bit deeper. Then I kind of wiggle it around, make sure that it is not, it is- one second, I'm gonna need it. Make sure it's not teetering. Okay, good. Do you see that thing? So this is confirmation that your guidewire is in the space. You got it? Okay. Now I'm gonna make a tunnel. I'm gonna do it again. Like kind of put your finger around, and then... Okay. So now I'm gonna tunnel. So this is the exit and then entrance. So I have to go from the exit to the entrance. From here, tunneling. Tunneling. And it is gonna come out from this side. Okay? Okay. I'm giving back to you. So this is a kind of - the knot that is gonna be kind of anchoring here and they're gonna cause a fibrous scaring over the long term. So I like to keep it near the exit site. Some people keep it in the middle but never place it on the entry site. So now I'm in. Okay. Now I'm gonna need the Kelly clamp.

Now I'm gonna need the dilator. Thank you. Go in and come out. Another one. So this is a kind of dilator that came with a kind of sheath. So like this way, this is very flexible. This is kind of a bigger dilator. They came and lock. So I'm gonna dilate with this one and then I'm gonna leave this in the body and I'm gonna come out with the guide-sheath, okay? So, push it in. And then unhook, and then, this thing came out. Okay, I have guidewire with you.

Okay, do you have suction ready, right? I'm sorry. We already in. I'm sorry, we almost done. Yep, almost done. So, after I thread it all the way, I break it, and then while I'm threading with one hand, I'm pulling the sheath with the other hand. Like my thumb is pushing down, but my index fingers are pulling the sheath. Okay. So now, I have to check that it's not kinked. If that is kinked, then my... I know, I'm sorry. Okay, we are done.

Do we have suction? Yeah. This should not be that hard, is there any way? Want me cut this? Yeah, yeah, yeah. Can I get a scissor? Oh, here. How much did he get already? So this... Okay, I'm giving back. A thousand? One liter. Yeah, you can take it off. Okay, stop it. Okay, we're done. I think he's totally fall asleep. Okay. Can I get a cap? So we are done with draining and we have to kind of dressing. So you have to cover both sides. Both exit and the entrance, right? Because this foam is gonna be keeping patient more comfort. Okay, I'm done. And there is a number, numeric order. So one, two, and three. So this is two. It's easy to follow. Can I get another four by... Thank you. You know me. Thank you everybody. Can I move this? Sure. Because I want to... Okay, sir.

CHAPTER 10

So now, we are done with the procedure. So when I look out with the - we always check with the ultrasound first. When I look at the ultrasound, you might have noticed that there is a kind of a flattening of the diaphragm a little bit. That is because this fluid has been pushing down his belly. That is causing that dyspnea, shortness of breath. And also the fluid size is around 15 to 16 centimeter deep. And also if you look at in the CAT scan and this large pleural effusion and we call it the symbol of pleural effusion. If you look at the ultrasound images, there is no kind of partition or no scarring tissue along the line. So this is a simple, large pleural effusion with symptomatic positive. So, we did the indwelling pleural catheter placement under the sterile condition. There is the entrance site and exit site. It has to be around not too close or not too wide because if it is too close then that site can have a lost blood supply. And then it causes skin necrosis and abrasion. If it's too wide, then patient gonna have pain. You're gonna have a challenge when you make the tunnel. That's one thing to keep in mind. And the second thing is when you choose the site, remember this is the procedure to improve the quality of life. If you choose too posterior, they won't be able to sleep on the back. So you might wanna choose around kind of (indistinct) side of this area. So at least when they lie down on their back, there should not be any issue. And then for, this is a man, so we don't have to worry about it. If you can place in a woman, you also have to look about the bra line, right? Because you wanna avoid that bra line as well. If you have skin tag, this patient have a skin tag or a skin ulcer aberration, you might wanna avoid those area because this area gonna be covered with a kind of adhesive tape all the time. And then they're gonna have to remove and put it back multiple times a week. So that can cause a skin aberration as well. So the procedure went well. I use a simple kind of technique, which we use in majority of the kind of line placement and tube placement, and it is the same method. The only thing is the tunnel. What it does is that the tube does not come out from the entrance site, which usually happens in the kind of central line placement and chest tube placement. We have to make another tunnel through the sub-q layer and from the exit site gonna come out from the different site. That is gonna cause less infection rate over the long term. So this is the kind of technique that we use for the chemo port and the hemodialysis catheter. Indwelling pleural catheter placement, has been our first treatment or choice in management of the malignant pleural effusion. They do much better than doing other kind of pleurodesis method. And also the surgical chest tube method, or placing the chest tube and drained it kind of in hospital method as well because first of all, it can be done as outpatient and patient can go home at the same day and then they can affect- they can get the autopleurodesis by around like kind of a three-month time point or earlier than that. And the more you drain it, the faster you're gonna get it. So, this is kind of, again, the majority of the population is a malignant population. So we have to look about kind of how often they gonna spend in emergency room or in the hospital for this procedure. So this indwelling pleural catheter placement have been helping a lot of this population.